Imagine treating glaucoma without prostaglandin analogs, evaluating patients without OCT and recommending surgery to improve aqueous flow only for the most advanced, intractable cases. That was roughly the state of affairs in 1994, when we launched our first annual glaucoma report.
Latanoprost was still two years away from launch—beta blockers ruled the roost—and the cutting-edge diagnostic technology of the day was retinal tomography. Glaucoma surgery was, if anything, maximally invasive in those days, as MIGS procedures were at least a decade away. ALT was making waves as an early laser surgical alternative to meds, but its safer, better successor—SLT—had yet to arrive. The OHTS trial had only just begun enrolling patients that year, so good luck figuring out what to make of your ocular hypertensives. And the influence of genetics and nutrition on glaucoma rarely got mentioned outside of ARVO.
Needless to say, glaucoma care has gotten dramatically more sophisticated in the 23 years since our first report—but with one frustrating exception that tempers the success of all the others.
First the good news: The technology to view and assess the optic nerve and nerve fiber layer has advanced by leaps and bounds. Surgeons essentially invented a brand new category of procedures: minimally invasive glaucoma surgeries. And newer drugs have improved the ability to lower IOP effectively and comfortably for patients.
What hasn’t evolved? The target. IOP lowering remains the goal of every medical and surgical intervention in the toolbox. And it’s been so for decades. “Nothing is being developed at the moment that is fundamentally different than what already exists,” an author wrote back in our 1994 report. “With this prognosis, glaucoma’s legacy for frustrating patients and clinicians alike may very well continue until the next century.” Indeed it has.
I’m struck by the naiveté (or maybe call it optimism) of the subtitle we used on that 1994 article: “Despite advances, researchers are still years away from a cure.” That strongly suggests that a cure is possible, and it’s just a matter of time until we get there. Nobody talks like that anymore about glaucoma. If you do, write to me and tell me why; I’d truly like to hear from you.
Is there any serious work afoot in neuroprotection? In 2011, the Low-pressure Glaucoma Treatment Study showed a protective effect from brimonidine. But the clinical trials needed to study neuroprotective agents and bring them to market would be hugely complex and take many years to run. Perhaps genetics and nutrition will identify more modifiable risk factors, or ocular perfusion pressure and its effect on metabolic processes will open up new avenues of exploration. Let’s hope the field one day finally sheds its obsession with IOP.
For now, the tools and techniques of glaucoma care are better than ever, and our 23rd report helps you stay ahead of this complex field.